Psychiatric Medication Consent Form

Patient Name: Date of Birth: Date:

Medication Information

Medication Name(s): Prescribed Dosage/Frequency:

Purpose of Medication

Possible Benefits

Possible Risks/Side Effects

Alternative Treatments

I have read and understand the above information.

My questions have been answered.

I give my consent for the administration of the above medication(s).

Patient Signature: Date: Provider/Witness Signature: Date: